Traditional MedicarePrior AuthHigh impact
Codes added to Medicare MDR 10/1/20
Blue Cross Blue Shield of Rhode Island·RI · Oncology, Hematology, Neurology +1 more·Physician / Facility
Effective date
Oct 1, 2020
We identified it
Jun 19, 2026
Summary
Effective October 1, 2020, Medicare will require prior authorization through Prime for 10 new drug codes including specialty medications like gene therapy (Zolgensma), cancer treatments (Padcev, Enhertu), and other high-cost biologics. Any claims for these codes submitted without prior authorization will be subject to denial.
Action Required
By October 1, 2020: Billing team must update system to require prior authorization through Prime for codes C9061, C9063, J0223, J0791, J0896, J1429, J1558, J3399, J9177, J9358, and Q5121. Update encounter forms and EMR alerts to remind providers that prior auth is mandatory for these specialty medications. Claims submitted without prior authorization will be denied.